Open Access Open Badges Research article

Inequality in treatment use among elderly patients with acute myocardial infarction: USA, Belgium and Quebec

Julian Perelman1*, Amir Shmueli2, Kathryn M McDonald3, Louise Pilote4, Olga Saynina5, Marie-Christine Closon6 and TECH Investigators

Author Affiliations

1 Escola Nacional de Saúde Pública, Universidade Nova de Lisboa and CIESP, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-560 Lisbon, Portugal

2 School of Public Health, the Hebrew University, Jerusalem, Israel

3 Stanford University School of Medicine, Center for Primary Care and Outcomes Research, Stanford, USA

4 Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada

5 Stanford University School of Medicine, Center for Primary Care and Outcomes Research, Stanford, USA

6 Inter-disciplinary Center in Health Economics, School of Public Health, Université Catholique de Louvain, Belgium

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BMC Health Services Research 2009, 9:130  doi:10.1186/1472-6963-9-130

Published: 30 July 2009



Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.


We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993–1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income.


Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec).


The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.